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Lumbar Spinal Stenosis Care Pathway

Date of last update: September, 2024

About Lumbar Spinal Stenosis (LSS)

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Overview: LSS is a frequent cause of chronic low back and leg pain. It often results from a degenerative process that causes narrowing of the central spinal canal, lateral recesses, or intervertebral foramen. This narrowing compresses the neurovascular structures, leading to symptomatic LSS, most frequently in individuals over the age of 60. While LSS can also be congenital, this care pathway focuses on degenerative LSS. Symptomatic LSS is described as neurogenic claudication, which can be characterized by unilateral or bilateral leg symptoms. This can include pain, cramping, numbness, balance difficulty, or weakness. Symptomatic LSS is amenable to conservative care; however, underlying pathologies requiring medical attention should be ruled out such as cauda equina syndrome, fracture, infection, or tumour.

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Effective Management: Given its multifactorial and progressive nature, influenced by physical, psychological, social, and environmental elements, there is no one-size-fits-all treatment for LSS. The treatment approach should be comprehensive and individualized. Effective management is ethical, evidence-driven, transparent, flexible and responsive to the person’s needs. Essential interventions include education, reassurance, addressing psychosocial factors, maintaining activities of daily living, and self-care practices. Additional interventions are selected through shared decision-making to align with patient goals, ultimately optimizing their ability to function and participate in life. Continuous monitoring of progress and consistent assessment of outcomes against goals are crucial to ensure that care strategies remain aligned with the patient's objectives and best interests. Management can be conducted through in-person virtual or hybrid care.

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About the Care Pathway

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  • Principles: Based on recommendations drawn from established clinical guidelines, integrating the best available evidence, clinical expertise, and patient preferences. Treatments are aligned with current guideline-supported practices. Developed with input from professional leaders, clinicians, and researchers.

 

  • Target Audience: Supports clinicians who deliver conservative care, and informs those who do not but may see people with these conditions for referral or co-management. Provides essential, concise guidance on key steps of a clinical encounter, with access to detailed information by clicking on specific sections. Includes a downloadable one-page quick guide for quick access to key information.

 

  • Updates: Regular updates are communicated through social media to ensure users have current information. The care pathways are 'living' documents, reflecting the state of clinical practice and research evidence to our best knowledge at the time of development. They may be updated to ensure they remain current and evidence driven.

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  • ​Disclaimer: This care pathway is not intended to replace advice from a qualified healthcare provider.

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***CLICK HERE FOR A ONE-PAGE QUICK GUIDE: Lumbar Spinal Stenosis Management Quick Guide

1. Record Keeping

  • Document all findings and recommendations on an ongoing basis, including SOAP notes at each visit (subjective, objective, assessment, plan).

  • Adhere to jurisdictional standards.

2. Informed Consent

  • Document verbal consent for health history taking, physical examination, contact in sensitive areas.

  • Obtain written consent for treatment.

  • Adhere to jurisdictional standards.

3. Health History

  • ​Apply cultural awareness and trauma-informed care principles.

  • Sociodemographic: Age, gender, sex.

  • Main complaint: Location, onset, duration, radiation, frequency, intensity, character, aggravating/relieving factors, associated symptoms.

  • Body systems: Neurologic, cardiovascular, genitourinary, gastrointestinal, muscles and joints, eyes/ears/nose/throat, respiratory, skin, mental health, reproductive.

  • Health, lifestyle, family, social, and occupational history: Past medical conditions, medications (including opioids), injuries, hospitalizations, surgeries, diet, exercise, sleep habits, smoking, alcohol/substance use, family support, caregiver responsibilities, work/school environment.

  • Social determinants of health: Employment, childcare, education, nutrition, housing, domestic violence, child maltreatment, discrimination, isolation.

  • Previous treatments and responses: Effectiveness and any adverse events.

  • Beliefs and expectations: Understanding of their condition, treatment expectations.

  • Red, yellow, and orange flags (sections 4 – 6).

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Meaningful Outcomes:

4. Differential Diagnosis Requiring Medical Attention

 

ACTION: Refer to emergency care immediately for red flags:

  • Cauda Equina Syndrome: Saddle anesthesia, bladder/bowel dysfunction, bilateral radicular signs.

  • Spinal Infection: Immunosuppression, recent infection or surgery, TB (tuberculosis) history, unexplained systemic symptoms (e.g., fever, chills), IV drug use, poor living conditions.

  • Traumatic Spinal Fracture: Severe trauma.

 

ACTION: Refer to appropriate medical provider:

  • Non-traumatic Spinal Fracture: Sudden onset, localized severe pain, osteoporosis, corticosteroid use, female sex, older age (>60), history of spinal fracture or cancer.

  • Spinal Malignancy: Progressive pain, history of cancer, constitutional symptoms (e.g., fatigue, weight loss, night pain).

  • Inflammatory Arthritides (e.g., spondyloarthropathies): Morning stiffness >1 hour, constitutional symptoms (e.g., fatigue, weight loss, fever), symmetrical joint pain, joint swelling and deformity.

  • Referred Pain: (from abdominal/pelvic visceral conditions): Abdominal or pelvic tenderness.

  • Cervical Spondylotic Myelopathy: Gait disturbances, hand clumsiness, non-dermatomal numbness/weakness, bowel/bladder dysfunction, coordination problems.

5. Psychiatric Disorders (Orange Flags)

  • Symptoms of major depression, personality disorders, PTSD, substance addiction and abuse.

  • Screening tools: PHQ-9, GAD-7.

  • Action: Refer to appropriate provider/psychiatric specialist.

6. Psychosocial Factors (Yellow Flags)

  • Factors that may delay recovery: Fear of movement, poor recovery expectations, depression, anxiety, reduced activity, over-reliance on passive treatments, lack of social support, work-related issues, family issues, litigation or compensation claims; maladaptive coping mechanisms.

  • Screening tools: PHQ-9,  GAD-7, FABQ, ORT, PCS.

  • Action: Address these as part of conservative care, co-manage, or refer to an appropriate provider.

7. Physical Examination

  • Observation: Abnormalities, posture, balance, movements, facial expression, gait, walking capacity (measured by distance or time).

  • Range of Motion: Active, passive, resisted (flexion, extension, lateral flexion, rotation).

  • Palpation: Bone, joint, and muscle for tenderness, swelling, muscle tightness, or temperature changes.

  • Neurological Examination: Motor strength, sensory and reflex testing (L4, L5, S1); upper and lower motor neuron signs; balance testing (e.g. tandem gait, Romberg’s).

  • Special/Orthopedic Tests: Select as appropriate based on clinical judgment.

  • Advanced Diagnostics: Advanced imaging (e.g., MRI, CT) to guide diagnosis and surgical management.

8. Diagnostic Criteria for LSS

A. LSS with Neurogenic Claudication (central stenosis)

  • Location: Widespread lower extremity pain with or without LBP.

  • Signs/Symptoms: Aching, cramping, or burning pain, most commonly in both legs, but can be unilateral. May include tingling, paresthesia, numbness, weakness, and balance difficulties. Aggravated by extension activities (e.g., walking, standing); relieved by forward bending, sitting, or lying down.

  • Physical Exam: Pain reproduced by physical tests; possible neurological deficits.

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B. LSS with Radicular Unilateral Leg Pain (lateral recess or foraminal stenosis)

  • Location: Unilateral lower extremity pain with or without LBP.

  • Signs/Symptoms: Pain following a dermatomal pattern associated with a nerve root in one leg. Aggravated by extension activities (e.g., walking, standing); less influenced by postural changes.

  • Physical Exam: Pain reproduced by physical tests; possible neurological deficits.

9. Treatment Considerations for LSS (with central or lateral stenosis)

After providing a report of findings and obtaining written informed consent.

  • Core Interventions:

    • Education and reassurance: Inform patients about the nature of LSS and the importance of maintaining activity. Reassure them that neurogenic claudication is often manageable with conservative care.

    • Address yellow flags (psychosocial factors): Psychosocial factors such as fear-avoidance and depression should be identified and addressed early (e.g., education, CBT).

    • Maintain activities of daily living: To prevent deconditioning.

    • Self-care: Promote physical activity, nutrition, proper sleep hygiene, stress management, healthy body weight, no smoking/substance abuse.

    • Engage in social and work activities: Helps maintain mental and emotional well-being.

    • Exercise therapy: Walking, functional exercise, flexion-based exercise, strength training (home-based or supervised).

    • Medical referral/surgical consultation: For worsening symptoms or failed treatment (e.g., significant/progressive neurological deficits, severe pain unresponsive to conservative care).

 

  • Optional Interventions:

    • Manual therapy: E.g., spinal manipulation/mobilization, soft tissue techniques, clinical or relaxation massage.

    • Medications: E.g., serotonin-norepinephrine reuptake inhibitors, tricyclic antidepressants. Avoid long-term use and opioids.

    • Psychological or social support

    • Mind-body interventions: E.g., mindfulness, meditation, tai chi.

    • Mobility assistive devices: E.g., walkers, canes to help maintain mobility and functional independence.

    • Multicomponent biopsychosocial care: E.g., Combine exercise therapy, CBT and manual therapy.

10. Prognosis

  • Recovery: Depends on several factors (e.g., stenosis severity stenosis, treatment response, presence of neurological deficits, overall health). The majority of individuals with mild to moderate LSS have a favorable prognosis, but neurogenic claudication due to LSS can recur or persist.

  • Negative Prognostic Factors: Smoking, obesity, higher initial pain and disability levels, poor recovery expectations, mental health issues, persistent symptoms.

11. Ongoing Follow-up

  • Continuously realign treatment plan with patient’s evolving goals, feedback, outcomes, and clinical judgment.

  • Consider referral or co-management if no improvement within established timeline for treatment (e.g., 6-8 weeks).

12. Criteria for Discharge

  • Establish clear criteria for discharge (e.g., achieving initial goals, reaching a plateau, progressing signs and symptoms).

  • ​Discuss post-discharge plans, including self-management strategies and potential follow-ups.

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